After the shift change, which patient in the emergency department should the nurse prioritize for assessment?

A 39-year-old patient experiencing tenderness and swelling in the right calf following a flight.

A 58-year-old patient on anticoagulants for atrial fibrillation presenting with black stools.

A 67-year-old patient with a gangrenous foot ulcer and a weak pedal pulse.

A 50-year-old patient reporting sudden, severe upper back pain.

Answer and Explanation

The Correct Answer is B

Choice A rationale
A 39-year-old patient experiencing tenderness and swelling in the right calf following a flight may be experiencing deep vein thrombosis (DVT), a condition that can lead to serious complications such as pulmonary embolism if not treated. However, DVT is not immediately life-threatening in most cases.
Choice B rationale
A 58-year-old patient on anticoagulants for atrial fibrillation presenting with black stools is likely experiencing gastrointestinal bleeding, a common side effect of anticoagulant therapy. This can lead to severe blood loss, anemia, and hypovolemic shock, which can be life-threatening if not promptly addressed. Therefore, this patient should be prioritized for assessment.
Choice C rationale
A 67-year-old patient with a gangrenous foot ulcer and a weak pedal pulse likely has peripheral artery disease and an infection that could lead to sepsis if not treated. However, while this condition needs medical attention, it is not as immediately life-threatening as gastrointestinal bleeding.
Choice D rationale
A 50-year-old patient reporting sudden, severe upper back pain could be experiencing a number of conditions, ranging from musculoskeletal strain to aortic dissection. While an aortic dissection is a medical emergency, without additional symptoms such as chest pain, shortness of breath, or loss of consciousness, this patient is not the highest priority.

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Correct Answer is A

Explanation

Choice A rationale
Pericardiocentesis is a procedure that uses a needle to remove fluid from the pericardial sac. This procedure can be used to relieve pressure on the heart caused by a large pericardial effusion.
Choice B rationale
A pericardiectomy is a surgical procedure that removes part or all of the pericardium. It is typically used to treat constrictive pericarditis, not pericardial effusion.
Choice C rationale
Heart catheterization involves inserting a long, thin tube (catheter) into a blood vessel and guiding it to the heart. It is typically used to diagnose and treat certain cardiovascular conditions, not pericardial effusion.
Choice D rationale
A thoracotomy is a surgical procedure to gain access to the chest. It is typically used for lung, esophagus, or other chest organ operations, not pericardial effusion.

A. Sinus tachycardia at a rate of 110 beats/min. B. Blood pressure increase from 134/68 to 150/80 mm Hg. C. The patient reports feeling tired. D. Inversion of T waves on the electrocardiogram.

Correct Answer is D

Explanation

Choice A rationale
Sinus tachycardia at a rate of 110 beats/min is a normal response to exercise. During a stress test, the heart rate will naturally increase as the body’s demand for oxygen increases. A heart rate of 110 beats/min is within the expected range during moderate exercise.
Choice B rationale
An increase in blood pressure from 134/68 to 150/80 mm Hg is a normal response to exercise. During a stress test, blood pressure will naturally rise as the heart works harder to pump blood to the muscles. This increase is within the expected range during moderate exercise.
Choice C rationale
Feeling tired during a stress test on a treadmill is a normal response to exercise. Fatigue can occur as the body’s energy stores are used up during physical activity. However, if the patient reports extreme fatigue or other symptoms such as chest pain or shortness of breath, it may indicate a problem.
Choice D rationale
Inversion of T waves on the electrocardiogram during a stress test is a sign of myocardial ischemia, a condition in which the heart muscle is not getting enough oxygen. This could indicate the presence of significant coronary artery disease and is a finding that would necessitate immediate action.

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After the shift change, which patient in the emergency department should the nurse prioritize for assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient with severe pericarditis has developed a large pericardial effusion and is symptomatic. What type of procedure should the physician order to help treat this condition?

Correct Answer is A

Explanation

During a stress test on a treadmill, which observation by the nurse would necessitate immediate action?

Correct Answer is D

Explanation

Given the electrocardiogram tracing below for a client who is unresponsive and without a pulse, what should be the nurse’s priority action?

What nursing assessment finding would suggest inadequate renal perfusion in a patient being stabilized after an acute coronary syndrome (myocardial infarction)?

A patient with Peripheral Arterial Disease (PAD) has recently undergone Percutaneous Transluminal Angioplasty (PTA) of the lower extremity. Which assessment is crucial for the nurse to perform post-procedure?

Which medication, when noted in a patient’s history, will diminish the effects of Warfarin (Coumadin)?

Which patient statement indicates that the nurse’s teaching about sublingual nitroglycerin (Nitrostat) has been effective?

A patient is being admitted to the emergency department with intermittent chest pain. They provide a list of daily medications. Which medication from the list has the most immediate implications for the patient’s care?

In the context of interprofessional care of the client and family, where should a nurse position the stethoscope on the chest to assess a client’s apical heart rate?